Healthcare Costs in Older Adults with Diabetes Mellitus: Challenges for Health Systems and for Society

To the Editor: Diabetes mellitus and its complications are a great economic challenge for any health system. Many countries have a growing worldwide diabetes mellitus problem. Projections from 2010 to 2030 estimate that diabetes mellitus in adults aged 65 and older will increase by 207% (from 27 million to 83 million cases) in developing countries and by 81% (from 26 million to 47 million cases) in developed countries.1 As a consequence, the global economic burden for diabetes mellitus and comorbid conditions is projected to increase dramatically from 2010 to 2030.2 In this context, using evidence from the Mexican case, the incremental trends of the economic burden of diabetes mellitus in older adults is highlighted. For older adults, in addition to the high costs of health services, the increasing demand for health services in future years complicates the challenges.3 Mexico, like the United States, faces problems with health financing that are generating high expenditures for all involved.4 This study involved evaluative research based on a longitudinal study of epidemiological and economic changes in the Mexican healthcare system caused by diabetes mellitus in older adults. The population base consisted of 4,032,189 older adults diagnosed with diabetes mellitus, as reported in the National Health Survey.5 Information on direct costs was obtained using the instrumentation technique. Indirect costs were determined using a human capital model developed for Latin America, based on premature mortality and temporary and permanent disability attributable to diabetes mellitus.6 To estimate the epidemiological changes for 2014 to 2018, a model was constructed according to the Box-Jenkins technique, 95% confidence intervals, and the Box-Pierce test (P < .001). For primary outcomes, 2015 was the cutoff. Table 1 shows the distribution of total costs. Direct costs represent 44% and indirect costs 56% of total costs. With respect to direct costs, the greatest effect comes from medicines, followed by outpatient services, and to a lesser degree, hospitalization. For the five main complications of diabetes mellitus, the greater effect is for nephropathy, followed by retinopathy, cardiovascular disease, neuropathy, and peripheral vascular disease. With regard to the relative weight of the economic burden according to origin of costs, the greatest economic burden was in out-of-pocket costs; for each $100 spent on diabetes mellitus in Mexico, $52 come out of pocket and $48 from the public health system. The indirect costs are distributed in three categories of estimation: premature mortality (5%), permanent disability (93%), and temporary disability (2%). Diabetes mellitus co-occurs with many other chronic conditions, more so in those aged 65 and older than in those who are younger (6.5 vs 2.9 conditions, respectively, in the United Kingdom).7 The results of the current study, like those from other countries, regarding comorbid conditions show that these add to costs of diabetes mellitus treatment. Governments of developing countries spend less per capita on diabetes mellitus, leaving substantial costs to be paid by other means. In this sense, older adult Mexicans with diabetes mellitus incur large out-of-pocket expenses. Even in the more-affluent United States, Medicare beneficiaries have an annual median out-of-pocket expense of $3,241 per person.8 There is an urgent need for diabetes mellitus prevention efforts worldwide. In Mexico, like in the United States, almost 50% of older adults have prediabetes mellitus. In the United States alone, each day since January 1, 2011, approximately 10,000 adults turned 65—an anticipated trend for the next 17 years.9 There is a need for intensified public health efforts by all countries addressing the unique national and individual burdens associated with diabetes mellitus management and prevention in older adults. This is a priority for the health system and for society. More resources need to be allocated to the design of new strategies to move from a treatment approach to one of prevention. In all countries, there is little or no intervention for the population with prediabetes mellitus.10 By shifting priorities, individuals’ catastrophic expenditures will decrease, and the high costs of temporary disability, permanent disability, and premature death that diabetes mellitus generates in older adults will diminish. New models and programs of care need to be implemented that can respond to the diverse health services that will be needed as a result of the epidemiological transition, particularly for diabetes mellitus and hypertension in older adults. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Arredondo, Aviles: acquisition of subjects and data, data analysis and interpretation, preparation of manuscript, review of manuscript. Arredondo: study concept and design. Sponsor's Role: None.

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